[Color and form changes in the iris]. / Farb- und Formveränderungen der Iris.

BACKGROUND: The high variability of iris structures can be used for diagnostic purposes. METHODS: An overview of the numerous changes visible at the slit lamp and possible diagnosis. RESULTS: Short description of possible irispathology with hints on pathology and treatment.

[Radiotherapy of exudative senile macular degeneration. A prospective controlled study]. / Strahlentherapie der exsudativen altersabhängigen Makuladegeneration. Eine prospektive kontrollierte Studie.

UNLABELLED: Despite the successful therapy of subretinal neovascular membranes by laserphotocoagulation there are many problems to be overcome. In the case of subfoveolar neovascularization, photocoagulation leads to a sudden decrease in visual acuity. Recently radiotherapy is considered as an alternative. Complications and effectivity were evaluated in this prospective and randomized trial. The initial results are presented. PATIENTS AND METHODS: There are 76 patients (51 women, 25 men, average age 77.7 +/- 8.6 years) included in the prospective randomized study. All of them show subfoveolar neovascular membranes in FLA and a decrease in visual acuity between 0.05 and 0.5. They were randomly assigned to either the radiotherapy or the control group. Radiotherapy was done within 6 days by 6 x 2 Gy (6 MV photons). The follow-up was at 4 weeks, after 3 months, after 6 months and then every 6 months after the end of radiotherapy. On average the follow-up is at 15.1 months. RESULTS: Concerning age and visual acuity before therapy, the control group and the radiotherapy group were not significantly different. At 4 weeks after radiotherapy, visual acuity was 0.13 +/- 0.46 (LogMAR). After 12 months, visual acuity at a distance was 0.11 +/- 0.30 in the therapy group and 0.09 +/- 0.13 (P = 0.838) in the control group. Patients with a preoperative visual acuity better than 0.2 improved more after radiotherapy. Metamorphopsy improved in 75% of the therapy group. The following complications could be observed: In the control group 3 patients suffered subretinal bleeding, in the radiotherapy group 3 patients, respectively. CONCLUSIONS: At present, the follow-up is too short to recommend radiotherapy as a standard procedure in the case of subfoveolar neovascularization. The results in patients with a better preoperative visual acuity encourage us to continue this study.

[Partial sphincterectomy in cataract surgery. Clinical and patho-histologic results]. / Partielle Sphinkterektomie in der Kataraktchirurgie. Klinische und pathohistologische Ergebnisse.

BACKGROUND: We perform partial sphincterectomy during cataract surgery in cases with very small pupil (< 3 mm). We assume that the small pupil is mainly due to a fibrosis ring of the sphincter muscle. PATIENTS: In 35 patients we performed the complete ophthalmological routine checkup. The pupil diameter was analysed by perimeter: a base value, with light, and in pharmaceutical mydriasis. Moreover 15 preparations were analysed histologically. RESULTS: Average pupil diameter was: base value 3.76 mm, with light 3.24 mm, in pharmaceutical mydriasis 4.84 mm. The showed pathohistological examination that in all excisions a part of the sphincter muscle was verifiable. We found fibrosis of different grades in various locations. CONCLUSION: In most cases functional pupil movement can be verified after operation. In an intended partial sphincterectomy part of the sphincter muscle can be excised. The different pupil diameter is due to the different degree of fibrosis of the sphincter muscle.

[Cataract surgery at the Berlin Virchow clinic. Overview of the last 16 years]. / Kataraktchirurgie am Virchow-Klinikum-Berlin. Uberblick über die letzten 16 Jahre.

PURPOSE: The aim was to compare the different techniques of cataract surgery regarding early postoperative astigmatism and visual acuity. PATIENTS AND METHODS: The data of three groups of patients (100 eyes) were analyzed retrospectively (1980-1982; 1987-1990; 1991-1993). Three different techniques of cataract surgery were used. Included in the prospective study were the data for 285 eyes, which underwent phacoemulsification, self-sealing incision and controlled induction of astigmatism. RESULTS: In the time period retrospectively investigated, we found that because of the advancements in operation methods, there was a reduction in the amount of surgically induced astigmatism. From 1980 to 1995 there was a clear increase in the number of patients with early low-grade postoperative astigmatism < 1 D (1980-1982: 6%, 1987-1990: 19%, 1991-1993: 64%, 1994-1995: 84%). There was an improvement in postoperative vision (with correction > 0.5) of 16% in 1980-1982 to 45% from 1987 to 1990, 58% from 1991 to 1993, and to 76% in 1994-1995. CONCLUSIONS: Surgical induced a stigmatism, which was considered to be a sign of unwanted increased postoperative astigmatism, was reduced from 1980 to 1993. Through controlled induction of astigmatism it was possible to compensate for preoperative astigmatism in the prospective group. Improved surgical techniques led to improvements in early postoperative visual acuity.

Contrast sensitivity after implantation of diffractive bifocal and monofocal intraocular lenses.

PURPOSE: To compare contrast sensitivity (CS) after implantation of a diffractive bifocal intraocular lens (IOL) and a monofocal IOL of similar design. SETTING: Seven European centers. METHODS: In this randomized, prospective study, CS was tested 5 months after cataract and IOL implantation surgery in 115 patients with a diffractive bifocal IOL and 106 patients with a monofocal IOL. It was also tested in a subgroup of 38 patients who had bilateral implantation of a diffractive bifocal IOL. Contrast sensitivity was tested using the Vision Contrast Test System (VCTS). RESULTS: In patients with a best corrected visual acuity (BCVA) of 1.0 or better, the CS at all spatial frequencies (1.5 to 18 cycles/degree), both at distance and near, was slightly lower in the bifocal IOL group than in the monofocal group. Mean values were within the normal range. In patients with a BCVA of less than 1.0, the CS was lower and the difference between the bifocal and monofocal groups was less. In patients with bilateral bifocal IOLs, CS was better when tested bilaterally than when testing the better eye alone. Pupil size affected the results to a small degree. Contrast sensitivity appeared to improve over time after implantation of a diffractive bifocal IOL. CONCLUSIONS: In patients with cataract and no other eye pathology, the diffractive bifocal IOL with slightly reduce the CS at all spatial frequencies. In those with reduced visual acuity after cataract surgery, CS will be reduced accordingly. In this situation, the reduction from the diffractive bifocal optic would be minor.

Intraocular pressure in nonglaucomatous eyes with pseudoexfoliation syndrome after cataract surgery.

BACKGROUND AND OBJECTIVE: To investigate the course of the intraocular pressure (IOP) in nonglaucomatous patients with pseudoexfoliation (PSX) syndrome after cataract surgery. PATIENTS AND METHODS: In a prospective age-matched controlled clinical study, 23 consecutive patients with PSX were studied and compared with a control group of 23 patients. The IOP was measured by applanation tonometry preoperatively, and postoperatively on day 1, after 4 weeks, and after 6 months. All patients were operated on with a self-sealing 7-mm scleral tunnel incision, phacoemulsification, and posterior chamber intraocular lens (IOL) implantation. RESULTS: Preoperatively the IOP was similar between both groups (P = .962). At the first postoperative day the IOP was below 22 mm Hg in all cases. After 4 weeks and 6 months a mean decrease of 3.88 mm Hg (P = .001) in the control group and of 3.15 mm Hg (P = .002) in the PSX group was observed; this difference was not statistically significant (P = .543). CONCLUSIONS: At 1 day postoperatively no pressure increase was observed in the eyes with PSX after scleral tunnel incision and phacoemulsification. Six months after cataract extraction with IOL implantation, the tension level decreased in the presence of PSX similarly as in normal eyes.

[Prospective comparison of 2 multi-focal lens models]. / Prospektiver Vergleich zweier Multifokallinsenmodelle.

BACKGROUND: The functional results of two different types of multifocal intraocular lenses (based on the diffractive and refractive principle, respectively) were investigated prospectively. MATERIALS AND METHODS: Altogether 50 patients who had a multifocal lens implanted were examined 4-6 weeks postoperatively. Visual acuity for distance and near vision, contrast sensitivity, low contrast visual acuity and glare visual acuity were investigated. RESULTS: Distance visual acuity, contrast sensitivity, low contrast visual acuity and glare visual acuity did not show significantly different results. Near visual acuity was statistically significantly better with the diffractive type of multifocal lens (because of a stronger adjustment for near vision). When the focus depth was tested by defocus curves, both lenses had better results within different areas of defocus. CONCLUSIONS: All patients in both groups showed satisfactory results. When choosing a multifocal intraocular lens, the individual needs of each patient should be taken into consideration.

Corneal endothelial cell changes in pseudoexfoliation syndrome after cataract surgery.

OBJECTIVE: To characterize possible differences in endothelial cell changes after cataract surgery in patients with pseudoexfoliation syndrome (PSX). METHODS: In this prospective, age-matched, controlled clinical study, 25 consecutive patients with PSX and 25 control patients with senile cataracts only were studied. All patients were treated with standardized cataract surgery. Sequential quantitative and qualitative morphometric endothelial cell analyses of the central and paracentral cornea were performed preoperatively and postoperatively at 1 day, 4 weeks, and 6 months using noncontact specular microscopy. RESULTS: Preoperative endothelial cell counts were 9.9% (P<.05) lower in patients with PSX (2387+/-266 cells/mm2) than in controls (2648+/-349 cells/mm2). The mean endothelial cell loss was 11.1% in the PSX group and 10.3% (P<.001 for both) in the control group, with no intergroup differences after 6 months. The mean endothelial cell area increased in both groups. Also, qualitative analysis revealed no significant differences in the endothelial repair mechanisms. CONCLUSIONS: Endothelial cell density is reduced preoperatively in patients with PSX compared with age-matched controls. In patients with PSX, cataract surgery induced similar endothelial cell changes without increased endothelial cell loss postoperatively.

Causes of severe decentration and subluxation of intraocular lenses.

BACKGROUND: Severe decentration and subluxation of intraocular lenses (IOLs) may lead to double vision, glare and deterioration of vision to the point of functional aphakia. The purpose of the present study was to analyse causes for severe IOL dislocation. MATERIAL AND METHODS: Between January 1989 and January 1996, 37 patients required IOL exchange because of decentrated or subluxated posterior chamber lenses. Twenty-five of the exchanged lenses were implanted in our hospital, 12 lenses elsewhere. After explantation the lenses were examined by light and electron microscopy. RESULTS: In 10 eyes, asymmetric implantation of the posterior chamber lens was responsible for decentration. Three of the lenser concerned were multifocal IOLs. Asymmetric implantation led to a significantly higher rate of explantations in eyes with multifocal lenses (P < 0.005). In five eyes decentration developed due to asymmetric capsular shrinkage, in four eyes due to posterior synechiae. A lens subluxation developed in three eyes as a result of rupture of the posterior capsule and in nine eyes because of zonular defects. In three cases decentrations were induced by an extensive secondary cataract. Macroscopically visible changed geometry of the haptics was found in nine lenses; eight of these had polypropylene haptics. Seven lenses showed severely altered haptics on electron-microscopic examination. In four eyes subluxated lenses had to be explanted together with the capsular bag because of severe defects of the zonula, which caused decentration in nine eyes. CONCLUSIONS: Asymmetric implantation of posterior chamber lenses should be strictly avoided. Multifocal lenses require special attention concerning symmetric capsulorhexis and positioning of their haptics.

[Cataract surgery in narrow pupil and postoperative fibrin reaction, especially after sphincterectomy]. / Kataraktchirurgie bei enger Pupille und postoperative Fibrinreaktion, insbesondere nach Sphinkterektomie.

BACKGROUND: Since increased intraoperative iris irritation can lead to increased postoperative inflammation, we are interested in postoperative reactions to several varied surgical procedures. We performed pupil stretching, iridotomy with iris suture, and partial sphincterectomy. MATERIALS AND METHODS: From January 1995 to January 1996, 100 patients (103 eyes) with narrow pupils underwent cataract surgery. In 13 eyes a iridotomy and iris suture were performed, in 28 eyes a partial sphincterectomy. In 62 eyes there was no surgical intervention after pupil stretching. Postoperative examinations were carried out in the early postoperative phase (up to 5 days postoperative) as well as 4 weeks after surgery. Fibrin reaction was classified according to 3 grades, (1) faint fibrinous threads, (II) fibrinous net, and (III) membranous fibrin exsudation. RESULTS: In the group without additional surgery there was a fibrinous reaction of grade I and II in 11 eyes. This complication occurred after iridotomy and iris suture in four cases and after sphincterectomy in four cases. While the intensity of fibrinous reaction was comparable in the first two groups, the fibrinous reaction after sphincterectomy was more intensive in one eye (grade III). However, response to intensive local antiphlogistic therapy was good. Frequency of fibrinous reaction in the three groups was statistically not significant. It should be pointed out that there was a partial restoration of pupil movements through sphincterectomy: mean pupil diameter was 4 mm, and 2.5 mm under exposure to light. Three patients had no pupillary reaction at all. CONCLUSIONS: Partial sphincterectomy facilities intraoperative manipulations of cataract surgery. Postoperative inflammatory reaction is rare and was very responsive to medical treatment. The reconstruction of pupillary movement is part of full visual function and, last but not least a round pupil is aesthetically more desirable.

A prospective evaluation of a diffractive versus a refractive designed multifocal intraocular lens.

OBJECTIVE: To evaluate prospectively a diffractive (811E, Pharmacia; power add +4.0 D) versus a refractive (PA154N, Allergan; power add +3.5 D) designed multifocal lens. PARTICIPANTS: Eighty patients planned for cataract surgery without additional ocular pathologies were randomized into the diffractive or refractive group, respectively. INTERVENTION: A standardized no-stitch phacoemulsification with implantation of one of the two multifocal lenses was performed in each patient. MAIN OUTCOME MEASURES: Distance and near-visual acuity, contrast sensitivity, low contrast visual acuity, glare visual acuity, and depth of focus were measured after surgery. RESULTS: All treated patients had best-corrected visual acuities of 20/30 or better. Near-uncorrected vision was significantly better (P < 0.0001) with the diffractive lens (mean, J1) than with the refractive lens (mean, J4). Low contrast visual acuity (61 +/- 12% versus 59 +/- 9%), glare visual acuity (39 +/- 19% versus 38 +/- 14%), and contrast sensitivity (1.48 +/- 0.08 versus 1.50 +/- 0.12) were not significantly different between the groups. CONCLUSIONS: Both lens designs showed satisfactory functional results with advantages for the diffractive lens design.

Combined phacoemulsification and filtering surgery with the 'no-stitch' technique.

OBJECTIVE: To determine if intentionally making a radial incision could lead to a lasting decrease in intraocular pressure and the development of filtering blebs. METHODS: Forty-three eyes treated with combined filtering surgery were compared with a control group of 42 eyes treated with cataract surgery (phacoemulsification) alone. All of the patients had advanced chronic open-angle glaucoma. During combined cataract and glaucoma surgery, the tunnel floor was transected with Vannas scissors. RESULTS: One year after surgery, the mean intraocular pressure in the study group decreased 7.6 mm Hg from a preoperative mean (+/-SD) of 25.9+/-5.3 mm Hg. The decrease in the control group was 3.7+/-4.2 mm Hg. The difference between the 2 groups was statistically significant (P<.001). In the study group, an average of 1.5+/-0.8 fewer medications were required 1 year after surgery. In the control group, 0.5+/-0.6 fewer medications were required. CONCLUSIONS: The combined surgical procedure discussed in this article led to a lasting decrease in intraocular pressure. Cataract surgery alone using the no-stitch technique and posterior chamber lens implantation also reduced intraocular pressure, although significantly less.

Inadvertent use of chlorhexidine instead of balanced salt solution for intraocular irrigation.

In three consecutive cataract operations, chlorhexidine was inadvertently used as an intraocular irrigating solution as a result of inattentiveness of an assistant. In two of the three patients, corneal endothelium damage was so severe that penetrating keratoplasty had to be performed. Further effects included pronounced iris atrophy, anterior chamber applanation, and a retrocorneal membrane. In one case, an increase in intraocular pressure developed. No effects were observed in the retina or optic nerve. Inadvertently using chlorhexidine for intraocular irrigation has far-reaching consequences for the affected eye and is recognizable by streak formation in the anterior chamber when intraocular infusion is initiated. To avoid such mistakes, the markings of the two bottles should be of different colors.

[Long-term prospective study of the development of corneal astigmatism in no-stitch cataract surgery]. / Prospektive Langzeitstudie zur kornealen Astigmatismusentwicklung bei der No-stitch-Kataraktchirurgie.

BACKGROUND: Several studies have confirmed, that the no-stitch technique results in early stabilization of astigmatism. In these papers, however, the follow-up was quite short. Former studies about sutured corneoscleral incisions have shown that even after some years astigmatism increased. Therefore, in this prospective study we investigated the change of induced astigmatism 5 years postoperatively. METHODS: The prospective study included 66 patients with scleral tunnel incisions who were monitored up to 5 years. Mean age was 74.3 +/- 10.7 years. The incision length of the scleral tunnel was 7 mm. The postoperative astigmatism was measured with keratometry after 1 day, 3 weeks, 1 year and 5 years postoperatively. RESULTS: The average postoperative induced astigmatism (PIA) as measured with a keratometer was after 1 year 0.95 +/- 0.83 D. After 5 years PIA was 0.96 +/- 0.48 D, and therefore no significant statistical difference could be shown. At the first postoperative day (0.94 +/- 0.73 D) the induced astigmatism was virtually stable. There was also no statistically significant difference in absolute astigmatism. After 1 day the absolute astigmatism was 0.91 +/- 0.73 D and after 5 years 0.96 +/- 0.61 D. CONCLUSIONS: The contrast to former sutured corneaoscleral incisions, the no-stitch technique in cataract surgery yields stable postoperative corneal astigmatism.

Photovaporization rate and profile of an erbium-chromium:YAG laser in the fundamental mode.

PURPOSE: To evaluate the ablation characteristics of an experimental erbium:YAG (Er:YAG) laser and assess whether it delivers sufficient output for performing photorefractive keratectomy. SETTING: Department of Ophthalmology, Virchow-Clinics, Humboldt University, Berlin, Germany. METHODS: An experimental Er:YAG laser, the erbium-chromium:YAG, running in fundamental mode was used to evaluate the energy profile. Measurements obtained using a joulemeter were compared to the ablation profiles of cadaver pig eyes. The pig eyes were treated with different fluences (mean 0.8 to 2.9 J/cm2) and, after histological preparation, were examined using light and scanning electron microscopy. RESULTS: Measurements with the joulemeter and in the cadaver pig eyes showed a Gaussian-curved profile of energy (ablation). In the current setting, the diameter of ablation was 3.5 mm. Histological examination showed a homogeneous profile of ablation with minor thermal damage. CONCLUSION: The Er:YAG laser running in the fundamental mode allows homogeneous ablation of corneal tissue. The Er:YAG laser is easier to handle technically than the excimer laser and has none of the potential risks of ultraviolet light.

[Early postoperative endothelial cell loss after corneoscleral tunnel incision and phacoemulsification in pseudoexfoliation syndrome]. / Frühpostoperativer Endothelzellverlust nach korneoskleralem Tunnelschnitt und Phakoemulsifikation bei Pseudoexfoliationssyndrom.

INTRODUCTION: Corneal endothelial involvement can be found in pseudoexfoliation syndrome (PEX). Evaluation of possible differences in endothelial cell loss following cataract extraction was compared to normal eyes. PATIENTS AND METHODS: In a controlled clinical study we prospectively studied 20 patients with PEX and compared them with an age-matched control group with senile cataract. All patients were treated with a standardized self-sealing 7-mm corneoscleral tunnel incision, phacoemulsification and posterior intraocular lens implantation using sodium hyaluronate. In addition to a complete ophthalmological examination, quantitative and qualitative endothelial cell analysis of the central and peripheral cornea was performed preoperatively, at the first postoperative day and after 4 weeks using non-contact specular microscopy (Konan Noncon Robo-ca SP 8000, Konan, Japan). RESULTS: In eyes with PEX (2394 +/- 271 cells/mm2) endothelial cell counts were 10.5% (P < 0.05) lower than in the control group (2674 + 341 cells/mm2). Intraoperatively, ultrasound time (90 +/- 51 s) and power (38 +/- 17%) did not differ between the two groups. After 4 weeks the mean endothelial cell loss in the two groups was 10.4% and 9.8%, respectively (P < 0.001). The mean cell area increased by 55 and 48 microns2 (P < 0.001), respectively. Polymegethism increased postoperatively in both groups and stabilized at 4 weeks at preoperative values. Pleomorphism increased significantly only in the PEX group. CONCLUSIONS: In eyes with PEX no increased cell loss was found in the early postoperative period compared to normal eyes following corneoscleral tunnel incision and phacoemulsification. Due to preoperative reduced endothelial cell densities, endothelium-protecting measures are recommended in eyes with PEX.

Postoperative astigmatism and relative strength of tunnel incisions: a prospective clinical trial.

PURPOSE: To investigate the influence of incision depth and site on wound strength and postoperative astigmatism. SETTING: Virchow Memorial Hospital Eye Clinic, Berlin, Germany. METHODS: In this prospective, randomized study, 180 patients with a 7.0 mm tunnel incision depth of 300 and 500 microns; limbal incision and scleral incision; temporal scleral incision and scleral incision at the 12 o'clock position; temporal limbal incision and limbal incision at the 12 o'clock position. Postoperative astigmatism was measured by keratometry and videokeratoscopy 1 day, 1 and 4 weeks, and 8 months postoperatively. Wound strength was measured with an ophthalmodynamometer on the first postoperative day and after 1 week at the site with the least mechanical stability adjacent and posterior to the primary incision. RESULTS: The temporal incision, which was performed 1.0 mm behind the surgical limbus, led to induced astigmatism of 0.65 diopters (D) +/- 0.23 (SD) after 8 months. When incision was at the 12 o'clock position, the induced astigmatism was 0.97 +/- 0.41 D. Induced astigmatism was highest following a limbal incision in the 12 o'clock position (1.33 +/- 0.63 D). This effect was less pronounced with a temporal incision. Incision depth did not significantly influence induced astigmatism. An incision depth of 500 microns led to induced astigmatism of 0.94 +/- 0.50 D; a depth of 300 microns led to induced astigmatism of 0.78 +/- 0.64 D. After 1 week, wound strength was highest with temporal scleral incisions (38.6 +/- 2.1 kPa by ophthalmodynamometer) and lowest with limbal incisions in the 12 o'clock position (30.8 +/- 7.7 kPa). CONCLUSIONS: Incisions site significantly influenced mechanical wound strength and induced astigmatism; incision depth influenced neither. In general, incisions in the 12 o'clock position induced more astigmatism than temporal incisions.

Effect of incision location on preoperative oblique astigmatism after scleral tunnel incision.

PURPOSE: To evaluate the effect of incision location or clinically relevant preoperative oblique astigmatism. SETTING: Department of Ophthalmology, Virchow Medical Center, Humboldt-University, Berlin, Germany. METHODS: This prospective study included 68 patients who had phacoemulsification and posterior chamber lens implantation using a standardized 7.0 mm self-sealing trapezoidal scleral tunnel incision. Each patient was randomly assigned to one of three incision locations: Group A, conventional superior incision; Group B, temporal incision; Group C, oblique incision centered on the steeper meridian (modified BENT incision). Astigmatism analysis was performed by manual keratometry and corneal topography. RESULTS: A significant mean reduction in astigmatism of 0.58 diopter (D) (P < .01) was achieved in only the modified BENT incision group. Postoperatively, significant flattening of 0.27 D (P < .01) in the steeper meridian as well as steepening of 0.29 D (P < .01) in the flatter meridian occurred. No decrease in astigmatism was noted in the superior or temporal incision groups. Five months postoperatively, vector analysis showed that surgically induced astigmatism was significantly higher in the superior incision group (1.16 D +/- 0.44 [SD]) than in the temporal incision group (0.66 +/- 0.32 D) or modified BENT incision group (0.82 +/- 0.50 D). Corneal topographic analysis confirmed these results within +/- 0.3 D. CONCLUSIONS: Only the oblique incision centered on the steeper meridian (modified BENT incision) effectively and predictably reduced preoperative oblique astigmatism. In eyes with clinically relevant oblique astigmatism, we recommend using a modified BENT incision.